Involuntary First Admissions to a Tertiary Psychiatric Hospital in Cape Town: a Five Year Review of Family Referrals to Psychology

Journal of Psychology and Clinical Psychiatry

Involuntary First Admissions to a Tertiary Psychiatric Hospital in Cape Town: A Five Year Review of Family Referrals to Psychology

Research Article Abstract Background: Valkenberg Hospital is one of three tertiary psychiatric hospitals Volume 4 Issue 1 - 2015 in Cape Town – and has a catchment area population of over one million. It is an acute admissions hospital for adults (18-59 years). Thornton HB1, Thornton D and Baumann S1 Objectives: This article aimed to determine the psychosocial history of male pa- Department of Psychiatry and Mental Health, University of tients involuntarily admitted to a high care psychiatric unit for the first time, and Cape Town, South Africa and Department of Health, South the needs and concerns of their families, to allow for the development of more Africa appropriate services. *Corresponding author: Helena B Thornton, Department Method: The psychology family clerking interviews (June 2007 – June 2012) of of Psychiatry and Mental Health, University of Cape the Male High Care Unit (MHCU) of Valkenberg Psychiatric Hospital’s first ad- Town, South Africa, Valkenberg Hospital, Private Bag X1, mission families (FAF) were reviewed. All of the patients in the chart review Observatory 7925, Cape Town, Tel: +27214403185; Fax: +27214403199; Email: were severely psychotic and had not been able to be managed at a secondary hospital level, which had necessitated their referral to Valkenberg. Each clerking Received: September 30, 2015 | Published: October 15, interview with the family lasted 1.5 to 2 hours, and was conducted by the Intern 2015 Clinical Psychologist placed at Male Admissions. All 225 available folders were reviewed and coded. Results: The majority of the patients were young (mode = 21), still living at home (80%), single (90%) and unemployed (65%).More than 80% of the men were given a working diagnosis of either Substance Induced Psychotic Disorder (SIPD: 46%), Schizophrenia (27%) or Bipolar (11%). There was a strong family history of severe mental illness (SMI: 49 %), psychiatric admissions (30%), depression (26%), suicide (18%), substance use (SUD in parent/s: 45%, siblings: 36%) and domestic violence (30%). Most families suspected that the patient had used drugs and police had had to be involved in at least 40% of the admissions. Despite nearly half of the patients expressing regret at their substance use, more than half the families reported that the patient had become aggressive and that at some stage they had feared them. The families most identified the patients’ admission as their greatest stressor. The second most identified greatest stress- or was finances, with 40% of the families being in debt and more than a third of the families being either unable to or financially struggling to visit the patient while he was admitted. Conclusion: For many patients and their families, the times before and during the admission had been long and traumatic. Family intervention was necessary to provide more effective help-seeking methods, and to provide services that simultaneously looked at co-morbid substance use, depression and anxiety, suicidal thinking, social isolation and domestic violence, often in the background of poverty. It was highly recommended that the development of services aimed at treating dual diagnosis (severe mental illness or the risk thereof, and substance use disorder) be developed and prioritised. Keywords: First episode psychosis; Substance use disorders; Dual diagnosis; Impact on families

Abbreviations: FA: First Admission; FEP: First Episode Introduction Psychosis; FHCU: Female High Care Unit; HIV: Human It is well documented that for families of people being : Male High Care Unit; PTSD: Post Traumatic Stress Disorder; SIPD:Immunodeficiency Substance Induced Virus; PsychoticICP: Intern Disorder; Clinical Psychologist; SMI: Severe Mental MHCU hadadmitted active for psychotic the first symptomstime, the pathway for 1-2 toyears care before can be treatment long and Illness; SUD: Substance Used Disorder; UCT: University of Cape [2,3],traumatic and [1].research For first suggests episode psychosisthat the longer(FEP), mostthe peopleduration have of Town untreated psychosis, the more the associated long-term disability

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[4]. Comorbid substance use, depression, suicidal thinking, social 2007 and June 2012, the Intern Clinical Psychologists had clerked avoidance and anxiety are common [5]. These can also potentially 225 FA families. lead to ineffective and demoralising help-seeking and a variety of traumatic events - one of which being the involuntary hospital Results admission [1,2]. Patient demographics generally followed that of the catchment The prevalence rate of aggression in mental illness, is typically population, except that patients were substantially under found to be more than half [6]. This is against a suggested employed for their age. The majority of patients were young background of higher levels of the patients’ premorbid exposure (mode = 21 years, 38% were between18-25, and nearly 75% to violence [7] – between 34% and 81% of patients with severe were in their teens or twenties), 90% were single, 80% had no mental illness (SMI), reported premorbid childhood and sexual dependants and 80% still lived with their family of origin. Sixty abuse, and between 43% and 81% of patients with SMI had had exposure to physical and sexual violence [8,9]. It is also known education (30% had Grade 12). Over 90% of all patients admitted, that the risk of violent behaviour increases with substance use spokefive percent a home were language unemployed common despite to the 60% Western having Cape10-12 (English: years of problems [10] and that half of FEP admissions have comorbid 38%, Afrikaans: 27%, Xhosa: 26%), and the majority of the substance diagnoses [11,12]. It is also known that the greater families reported to follow the Christian (71%) or Islamic (12%) exposure to violence by a family member is associated with greater faiths, or had “no religion” (11%). levels of trauma (including PTSD) for the families [13]. Risk for violence also increases with nonadherence with medication, poor biggest stress, despite 60% of the families owning their own levels of insight [10], dual diagnosis (SMI and substance use), and home.Nearly Forty a quarterpercent ofof thefamilies families reported felt that that finances they were were in debt,their if there was a family history of substance use and family history of mental illness [6]. a third of families either struggled to or could not afford to visit Most people presenting with FEP are young, and still living the75% patient. reported While that almostthey were all hadstruggling access financially,to piped water, and more 30% thanonly with their family of origin. Especially at the time of the onset of had cold water, and 5% of families used outside toilets. Generally, a mental disorder, and at the time of the diagnosis of the mental disorder, family members often experience strong emotional electricity (96%), had access to public transport (99%), and over reactions such as guilt, fear, disappointment, anger and relief [14]. 97%the familieshad access despite to a local their clinic. financial On average, difficulties, each accommodation had access to had 2.47 bedrooms, and an average of 4.54 people stayed in each Aim and Objectives family home. Most patients (55%) did not share their bedroom with someone else. Those that did share mostly shared with their Cape Town has a population exceeding 3.5 million [15], and siblings (18%), their mother (9%), or close family members (5%). Valkenberg Hospital is one of the three tertiary psychiatric hospitals that serve this population (each hospital therefore Nearly two-thirds of FA families (60%) reported the index covers more than a million people.) It is predominantly an acute admission to be their “biggest stress”, with nearly 40% needing admissions hospital for adults (18-59 years) and its Male High the police to be involved. Nearly three quarters of the FA Care Unit has a waiting list for admission of up to 50 men at any families (73%), suspected the patient had used drugs. On direct given time. The resultant bed pressure means the great majority questioning (n = 119 families), daily use of cannabis (51%), of people being admitted are very ill and involuntary. Intern methamphetamines (45%), and alcohol (32%) was reported. Clinical Psychologists (ICPs) working on the MHCU, concentrate More than half the families (56%) reported that the patient had their services on the families of psychotic patients who were been aggressive, and 29% reported that the patient had become “dangerously violent” or had made death threats, and nearly a First Admission (FA) families. third reported the patient to have been a perpetrator of domestic being admitted for the first time-these were referred to as the violence. While 95% of the families believed that the patient was The study reviewed the family clerking interviews conducted not a risk to the family when well, more than half reported the by the Intern Clinical Psychologists of the MHCU. The objectives patient to be a risk to them when he was ill, and more than half were to explore the patient’s psychosocial history, to examine the of the families (53%) reported that they had at some stage feared needs and concerns facing FA families, and to identify common the patient. However, more than half of the patients (55%) had needs that may suggest more appropriate services and allocation told their families that they wanted to give up or regretted their of resources. substance use. Methodology In 2006, members of the multidisciplinary teams (psychologists, families. Almost half the FA family histories were positive for There was a significant level of psychiatric illness within FA social workers, occupational therapists, doctors and nurses) of the High Care Admission Units met together to discuss an reported a family history of successful suicide (18%). Psychiatric severe mental illness (SMI: 49%) and nearly one fifth of families auxiliary clerking document that could be used with families to family histories also showed psychiatric admissions (30%), gain further collateral regarding the patient, and to record what anxiety (29%) and maternal depression (23%), and substance the families were experiencing and needing. From this, emerged use disorders (SUD in parent/s: 45%, siblings: 36%). what was to become the clerking document used by the Intern FA families also reported high levels of domestic and community violence. Nearly a third of the FA families (30%, n=168), reported and permission from UCT’s Ethics Committee and the research that the patient had premorbidly witnessed domestic violence, Clinical Psychologists (ICPs). All information was confidential and nearly a quarter of FA families reported that the patient had committee of Valkenberg Hospital was first gained. Between June

Citation: Thornton HB, Thornton D, Baumann S (2015) Involuntary First Admissions to a Tertiary Psychiatric Hospital in Cape Town: A Five Year Review of Family Referrals to Psychology. J Psychol Clin Psychiatry 4(1): 00178. DOI: 10.15406/jpcpy.2015.04.00178 Involuntary First Admissions to a Tertiary Psychiatric Hospital in Cape Town: A Five Copyright: 3/4 Year Review of Family Referrals to Psychology ©2015 Thornton et al.

premorbidly been a victim of domestic violence (24%, n=170). provided and prioritised, and the treatment teams for the dual Most families reported living in dangerous communities, and said diagnosis should be coalesced. This may reduce the occurrence of that the patient had often been a victim of community violence a SMI developing or worsening, and reduce the risk for violence. (41%, n=167), or had witnessed it (44%, n=154). These services must not simply offered to the patient, but also be available for the family. More than 80% of admissions had had one of the following working diagnoses: Substance Induced Psychotic Disorder (SIPD: Future Research 46%), Schizophrenia (27%) or Bipolar I (11%). Most families expected the patient to improve by 85% (n=150), and that this would take one week to a month (48%). Many families believed suggested. Psychology clerking interviews should provide more that it would take the patient 1 day to improve (6%), 1 day to directionBased foron psycho-educationthese initial findings, (e.g. riskseveral for futureclinical admissions directives andare 1 week to improve (6%), while alternatively, some felt it would how to avoid them). Family members (especially the mothers), take 1 month to 1 year to improve (37%) or more than a year to where there was a high risk for depression and anxiety, should be improve (5%). More than three quarters (77%) of the FAF families offered ongoing psychology services. More realistic interventions believed that the patient would never need another admission. regarding the patient’s substance use, especially if there was More than a quarter of the families felt that they wanted to have a high comorbidity of substance use by the patient’s parents, another session, although 11% of families explained that they siblings, neighbours and or friends, must be sought. It would be would phone later to ask for one, and 60% of families felt that the of help to list and liaise with the organisations and experts that the families had already contacted regarding the patient, prior to their admission. clerkingGenerally, session the (averaging families looked 1.5 hours), forward had (59%) been sufficient. to the patient’s return. A further 18% of FA families felt that they would conditionally accept the patient back (e.g., if they gave up drugs 5 years of the ICP family clerking interviews. Future research / if they were no longer violent), and 13% of FA families were shouldIn 2013, include the extending chart review the waschart completed, review to detailingthe FAF thefamilies first ambivalent about the patient’s return. where no appointment had been offered. Usually this would have been because of lack of contactable numbers for the family, or Even prior to the patient’s admission, many of the FA families that the family lived too far away, or if the psychology services had already accessed some level of help (39%), including accessing were overstretched and unable to provide cover. It may suggest mental health organisations / experts (20%), and substance use a bias against the families that were not contactable (possibly less resourced than those accessing the services). Resources families as providing support, were from friends and neighbours are limited, but it would be useful to compare FAF families of (64%)organisations and religious / experts support (17%). (61%). Other More areas than identified 72% of the by families, the FA male patients, to the experiences of the Female High Care Unit believed that it was the mother who had been the most negatively (FHCU) families. It was assumed that later comparative chart affected / stressed, by the patient’s admission, and 56% the FA prevalence. person responsible to help the patient with their medication. reviews would reflect a greater indentified concern regarding HIV families identified that it would be the mother who would be the It is necessary that psychiatric health care professionals Discussion take the initiative and responsibility for psycho-education and support of family members [14]. Loss, guilt, confusion and high It was noteworthy that despite the male population being levels of emotional distress make the need the early intervention programmes focusing on psychosocial and familial interventions crucial [17,18]. It is possible that family intervention in the early underemployedadmitted for the [15]. first Otherwise, time to their Valkenberg demographic Hospital variables being stages of psychosis may prevent the development of a critical tendedrelatively to be better consistent educated, with they the Cape were Town nonetheless population, significantly and the family atmosphere and the onset of the associated expressed emotion, and effectively postpone the onset of later relapses similar to the current reported literature. It was possible that [19-20]. Care-giver burden may be somewhat alleviated with theadmission high levels profile of forcomorbid first episode substance psychosis, use, the also high tended incidence to be improved community-based services for preventative long-term care, including medication adherence (rather than multiple poverty, may have made the Cape Town FEP community hospitalizations) [10]. particularlyof reported vulnerable. domestic and Despite community South Africa violence, having and a generalised significant HIV epidemic which has stabilised over the past several years Acknowledgment at a national antenatal prevalence of about 30% [16], the great majority of families (97%) denied that the patient (or any family The authors would like to thank the purchases of the services member) had HIV. at Valkenberg Psychiatric Hospital, all the members of the multidisciplinary teams, the management and all who assisted us Conclusion in this chart review. 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Citation: Thornton HB, Thornton D, Baumann S (2015) Involuntary First Admissions to a Tertiary Psychiatric Hospital in Cape Town: A Five Year Review of Family Referrals to Psychology. J Psychol Clin Psychiatry 4(1): 00178. DOI: 10.15406/jpcpy.2015.04.00178 Involuntary First Admissions to a Tertiary Psychiatric Hospital in Cape Town: A Five Copyright: 4/4 Year Review of Family Referrals to Psychology ©2015 Thornton et al.

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